AUA 2017: Survival Following Neoadjuvant Targeted Therapy and Cytoreductive Nephrectomy in Metastatic Renal Cell Carcinoma Patients
Previous studies on the effect of PTT on tumor and thrombus characteristics in advanced renal cell carcinomapatients did not show any differences in thrombus level or other tumor characteristics, indicating that targeted therapy may not have immediate local effects on these tumors. Another pertinent question that remains to be answered, however, is what the effect on survival is that PTT may confer to patients undergoing CN. Indeed, surgery is complex, and CN may be particularly risky for those with poor-risk disease characteristics. Hence, the question has merit.
The study’s authors identified 486 patients between 2000 and 2015 from five cancer centers in the United States. The two groups being compared were those who received PTT prior to CN (8%) versus those who underwent upfront CN (92%). There were no differences between thrombus level or risk grouping by Memorial Sloan Kettering Cancer Center or International Metastatic Renal Cell Carcinoma Database Consortium risk-predicting models.
For patients undergoing PTT, median therapy time was 12 weeks, and most patients were treated with either sunitinib or bevacizumab. Similar to findings in previous studies, there was no difference in thrombus level for most patients following PTT. Median overall survival analysis showed no difference in PTT versus upfront CN (26.2 months vs. 24.6 months, respectively, P = .36). However, for individuals with International Metastatic Renal Cell Carcinoma Database Consortium poor-risk disease, there was a nonsignificant, but quite dramatic, difference in median overall survival for patients undergoing PTT versus upfront CN (38.1 months vs. 13.4 months, respectively, P = .28).
The authors concluded that while there did not appear to be a survival benefit (at least in this time period) for treatment with targeted therapy prior to CN, there may be a signal that poor-risk patients could potentially benefit from presurgical treatment.
While these findings were certainly exciting, especially if poor-risk patients may one day be proven to have improved outcomes following PTT, this study had its inherent limits. The retrospective nature of the study could not control for all biases that led to the selection of those who received therapy before surgery, and this limited the power of the conclusions. Furthermore, only 8% of the study’s patients had PTT. Perhaps a more important result derived from this study was that PTT seemed not to have a major effect on survival outcomes, while CN itself showed a measurable benefit. With the current data, upfront CN seems the reasonable choice for most patients.
Presented by: Shivashankar Damodaran, MBMCH, and colleagues, University of Wisconsin
Written By: Shreyas Joshi, MD, Fox Chase Cancer Center, Philadelphia, PA
at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA